O/E |
Slow-rising, low vol pulse; Narrow pulse pressure; Undisplaced, sustained (heaving) apex; Ao thrill; ESM to carotids; Soft S2 |
Collapsing, large vol pulse; Wide pulse pressure; Displaced, hyperkinetic apex; Ao thrill; Early diastolic murmur (LLSE), Mid-systolic flow |
Malar flush; Small vol pulse; +/- AF; Undisplaced, tapping apex; RV heave; Loud S1 (mobile valve only); OS (after S2 mobile valve only) |
Small vol pulse; +/- AF; Displaced thrusting apex; Apex thrill; RV heave; Soft S1; Split S2 (early AoV closure); Loud P2 (PHT); PSM to axilla; S3 |
Severity |
Absent/soft A2; Delayed A2; Delayed ESM; Narrow pulse pressure; Slow-rising pulse; Thrill/heave; LVF; S4 |
Loud, short EDM; Soft S2; S3; Wide pulse pressure; LVF; Austin Flint; Hill's sign (SBP legs > arms) |
Longer MDM; OS nearer A2; PHT |
Displaced apex (?size LV); Signs of LVF |
Complications |
LVF, IE, Conduction dis |
LVF |
PHT, IE, Pulmonary oedema, CVA (thromboembolic), Haemoptysis/hoarseness |
IE, Pulmonary oedema |
Causes |
Congenital, Degenerative (calcified), Bicuspid, Rheumatic |
Congenital, Acute, Chronic Valv, IE, RhF, CTD (RA), Ao root, Trauma, Dissect, Dilatation (HTN, Marfan's) |
Rheumatic Fever, Congenital, Rare (SLE, LA myxoma, RA, Carcinoid) |
Congenital; Acute: IE, Acute MI; Chronic: IHD, RhF, CTD, MVP, Valvotomy, Amyloid, HCM |
ECG |
LVH, LBBB, LAD |
LVH, TWI |
P-mitrale, AF, RVH |
P-mitrale, AF, LVH |
CXR |
Normal +/- calcified valve |
Cardiomegaly, wide mediastinum |
Large LA, calcified valve |
Cardiomegaly, pulm oedema |
Echo |
Valve area < 0.5 cm² |
LVESD > 55 mm |
Valve < 1 cm²/m² |
LVEF < 55% |
Management (Mx) |
Asymptomatic: None unless gradient > 50 mmHg or worsening ECG (6/12 review, ppx Abx).
Symptomatic: AVR +/- CABG |
Acute: AVR.
Chronic: Symptoms before LV dysfunction, or pulse pressure > 100, ECG changes, LV enlarged on CXR |
Medical: Warfarin, Digoxin, diuretics (reduce preload), ppx Abx.
Surgery: Valvuloplasty, Valvotomy, MVR |
Medical: Diuretics, ACEi, Warfarin, ppx Abx.
Surgery: MV repair or MVR |
??dx |
VSD, HOCM, PS, MR, Flow murmur |
Mixed AoV Disease (AR/AS) — Pulse collapsing/slow-rising, Apex thrusting/heaving, Thrill absent/present, SBP high/low, Pulse pressure wide/narrow |
Austin Flint, Carey-Coombs (RhF), LA myxoma |
TR, VSD, AS |
Anything else? |
Listen for MS as they tend to reduce signs of each other |
Mixed MV disease (MR/MS) — Pulse sharp/small, Apex thrusting/tapping, S1 soft/loud, S3 present/absent |
Malar flush ddx: MS, SLE, acne rosacea, dermatomyositis, carcinoid, erysipelas |
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